The proposed project addresses the increasingly important issue of how hospitals and post-acute providers can collaborate to improve their patients' experience and reduce re-hospitalizations. There has been tremendous growth in post-acute care, particularly to Skilled Nursing Facilities (SNF), coinciding with increases in re-hospitalizations. Because Medicare policy has not levied penalties for re-admitting patients discharged to SNF, organizational strategies to ensure coordinated care across settings to prevent them are underdeveloped and hospitals' accountability for their patients' care upon discharge has been limited. Our proposal seeks to understand whether hospitals that preferentially discharge their PAC patients to a select number of SNFs mitigate the forces producing higher re-hospitalization since the hospitals and their preferred SNFs invest in coordinated transition protocols . There are provisions of the Affordable Care Act (ACA) designed to overcome reimbursement related barriers to collaboration between hospital and SNF. We propose to test their provisional effect on how hospitals and SNFs collaborate and the effect this has on re-hospitalization and related patient outcomes. Building upon a decade of national Medicare claims linked to SNF Minimum Data Set assessments and using a mixed quantitative and qualitative methodology, informed by transaction cost economics, we propose to: 1) develop and test a measure of hospital-SNF preferred provider relationship; 2) To estimate the effect of strong hospital-SNF relationships on the risk of 30-day re-hospitalization and nursing home residency, controlling for patient acuity, patient selection and market factors; 3) To empirically test the extent to which hospitals strengthen their partnerships (steer their discharged patients) to fewer SNFs in response to the introduction of ACA provisions and participation in ACO's and/or bundling initiatives overtime; and 4) to qualitatively examine the patterns of interaction and exchanges, at the administrative and clinical levels, between hospitals and SNFs to better understand markers of relationship strength as a qualitative test of our quantitative measure of hospital-SNF linkage.